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        <title>historia clinica</title>
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        <div>HISTORIA CLINICA</div>
        <div class="left">
            <label for="txtNombre"> Nombres: <span class="asterisco">*</span> </label> <input type="text" name="nombres" id="nombre" required></div>
             <div class="left">
            <label for="txtApellidos"> Apellidos: <span class="asterisco">*</span> </label> <input type="text" name="apellidos" id="apellido" required></div>
        <div class="right">
            <label for="txtIdentificacion"> Identificacion: <span class="asterisco">*</span> </label> <input type="text" name="identificacion" id="identificacion" required></div>
        <div class="left">
            <label for="txtEdad"> Edad: <span class="asterisco">*</span> </label> <input type="number" name="edad" id="edad" required></div>
        <div class="right">
            <label for="txtGenero">Genero<span class="asterisco">*</span></label>
            <label for="Maculino"><input type="radio" name="sexo" value="masculino"/>Masculino</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="Femenino"><input type="radio" name="sexo" value="femenino"/>Femenino</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="otro"><input type="radio" name="sexo" value="otro"/>Otro</label><br>
        </div>
        <div class="left">
            <label for="txtDireccion"> Direccion: <span class="asterisco">*</span> </label> <input type="text" name="direccion" id="direccion" required></div>
      
       
        <div class="right">
            <label for="txtFechaIngreso"> Fecha de Ingreso: <span class="asterisco">*</span> </label> <input type="date" name="fechaIngreso" id="fechaIngreso" required></div>
        <div class="left">
            <label for="txtFechaSalida"> Fecha de Salida <span class="asterisco">*</span> </label> <input type="date" name="fechaSalida" id="fechaSailda" required></div>
        <div class="left">
            <label for="txtEstado_civil">Estado civil:<span class="asterisco">*</span></label>
            <label for="txtSoltero"><input type="radio" name="estado_civil" id="estado_civil" value="soltero(a)" />Soltero(a)</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtCasado"> <input type="radio" name="estado_civil" id="estado_civil" value="casado(a)" />Casado(a)</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtDivorsiado"> <input type="radio" name="estado_civil" id="estado_civil" value="divorciado(a)" />Divorciado(a)</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtViudo"><input type="radio" name="estado_civil" id="estado_civil" value="viudo(a)" />Viudo(a)</label><br>
            &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<label for="txtUnion_libre"><input type="radio" name="estado_civil" id="estado_civil" />Union libre</label><br></div>
        <div class="left">
            <label for="txtDiagnostico"> Diagnostico <span class="asterisco">*</span> </label> <input type="text" name="diagnostico" id="diagnostico" required></div>
        <div class="left">
            <label for="txtLugar_nacimiento"> Lugar de nacimiento: <span class="asterisco">*</span> </label> <input type="text" name="lugar_nacimiento" id="lugar_nacimiento" required></div>
        <div class="left">
            <label for="txtT_movil"> Telefono movil: <span class="asterisco">*</span> </label> <input type="text" name="telefono_movil" id="telefono_movil" required></div>
        <div class="left">
            <label for="txtT_fijo"> Telefono fijo: <span class="asterisco">*</span> </label> <input type="text" name="telefono_fijo" id="telefono_fijo" required></div>
        <div class="right">
            <label for="txtVia_ingreso"> Via de ingreso: <span class="asterisco">*</span> </label> <input type="text" name="via_ingreso" id="via_ingreso" required></div>
        <div class="right">
            <label for="txtMotivo_consulta"> Motivo de consulta: <span class="asterisco">*</span> </label> <input type="text" name="motivo_consulta" id="motivo_consulta" required></div>
        <div class="left">
            <label for="txtEntidad"> Entidad: <span class="asterisco">*</span> </label> <input type="text" name="entidad" id="entidad" required></div>
        <div class="right">
            <label for="txtRegistrador"> Registrador: <span class="asterisco">*</span> </label> <input type="text" name="registrador" id="registrador" required></div>
        <div class="left">
            <label for="txtRemision"> Remision: <span class="asterisco">*</span> </label> <input type="text" name="remision" id="remision" required></div>
        <div class="left">
            <label for="txtFecha"> Fecha: <span class="asterisco">*</span> </label> <input type="date" name="fecha" id="fecha" required></div>



        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb<label for="txtAntecedentes_familiares">ANTECEDENTES FAMILIARES</label>
        <br><label for="txtRaya">_______________________________________________________________________________________________</label>
        <div class="left">
            <label for="txtDiabetes"><input type="checkbox" name="diabetes" id="diabetes" value="diabetes">Diabetes</label> </div>
        <div class="center">
            <label for="txtAsma"> <input type="checkbox" name="asma" id="asma" > Asma</label> </div>
        <div class="right">
            <label for="txtTuberculosis"><input type="checkbox" name="tuberculosis" id="tuberculosis" value="tuberculosis"> Tuberculosis</label> </div>
        <div class="left">
            <label for="txtCancer"><input type="checkbox" name="cancer" id="cancer" value="cancer">Cancer</label> </div>
        <div class="center">
            <label for="txtAlergia"> <input type="checkbox" name="alergia" id="alergia" value="alergia"> Alergia</label> </div>
        <div class="right">
            <label for="txtTabaquismo"><input type="checkbox" name="tabaquismo" id="tabaquismo" value="tabaquismo"> Tabaquismo</label> </div>
        <div class="left">
            <label for="txtHipertencion"><input type="checkbox" name="hipertencion" id="Hipertencion" value="hipertencion">Hipertencion</label> </div>
        <div class="center">
            <label for="txtEpilepcia"> <input type="checkbox" name="epilepcia" id="epilepcia" value="epilepcia"> Epilepcia</label> </div>
        <div class="right">
            <label for="txtAlcoholismo"><input type="checkbox" name="alcoholisto" id="alcoholismo" value="alcoholismo"> Alcoholismo</label> </div>


        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nb<label for="txtAntecedentes_prenatales">ANTECEDENTES PRE-NATALES</label>
        <br><label for="txtRaya">_______________________________________________________________________________________________</label>












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